CEC Falls Audit Tool – Ward LevelAudit No:

Select ward and randomly select 10 patient records. (This is not compulsory for your use if you wish).

Ward:Date: Author:

Criteria / Audit Activity / Met /Not met
(green/red) / Comments
Falls risk screen
completed on admission or within 24 hrs / Review clinical file for time and date of admission, and date of completion of Ontario screen.
Patient falls risk indentified / Review clinical file, falls risk score noted: patient bed/notice board for evidence of falls risk flagging ( eg falls risk sticker /alert in notes/care plan)
Falls risk assessment & management plan completed / Review clinical file, and care plan/– competed Falls Risk Assessment and Management Plan (FRAMP)
Falls interventions implemented documented – including relevant multidiscipline intervention / Review clinical file and care plan
Falls risk plans implemented in consultation with patient/
family and carers / Review clinical file: consult with patient/family carer
Patient/family/carer is provided with falls information / Falls information provided on admission/following a fall
Patient reassessed if change in condition,ward - falls risk screen completed / Review clinical file for time and date of revisions
Discharge information and referrals made (where appropriate) / Review clinical file discharge summary
Post fall observation and interventions completed (if patient fell) / Review patient file for the presence of the post –fall sticker/notes/observation chart
Patient fall risk status revised and care plan reviewed (after patient fall) / Review patient file and care plan

CEC Falls Audit Tool – Ward Level

Select ward and randomly select 10 patient records.

  • Audit Score = Number of complete charts for this audit.

Criteria / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / Comments
Falls risk screencompleted on admission or within 24 hrs
Patient falls risk indentified
Falls risk assessment & management plan completed
Falls interventions implemented documented – including relevant multidiscipline intervention
Falls risk plans implemented in consultation with patient/
family and carers
Patient/family/carer is provided with falls information
Patient reassessed if change in condition,ward - falls risk screen completed
Discharge information and referrals made (where appropriate)
Post fall observation and interventions completed (if patient fell)
Patient fall risk status revised and care plan reviewed (after patient fall)
Total Number of patient records meeting all criteria for this audit period / /10
Percentage / %

KEY:

  • Colour the box GREEN if criterion is meet
  • Colour the box RED if the criterion is not met
  • NA for those criterion that are Not Applicable
  • Only charts meeting ALL the audit criteria, ie ALL BOXES GREEN, are considered complete.
  • Score = number of complete charts for this audit.